Ray
Blanchard, Head of the Clinical Sexology Program of the Clarke Institute
of Psychiatry in Toronto, knows more about transsexualism than just about
anyone else. Like so many sex researchers, Blanchard's introduction to
sex research was fortuitous rather than intentional. A rat psychologist
by training, his first job was as a clinical psychologist at the Ontario
Correctional Institute. He worked full time evaluating and treating inmates
and was miserable. "I didn't want to spend 100 percent of my time
as a front-line clinician. I wanted to make a scientific contribution.
Plus, the prison environment was stressful, if never dull." During
that time, the eminent sex researcher, Kurt Freund, consulted at the hospital.
Someone suggested that they meet, and during their first conversation,
they made plans to collaborate. In 1980 Blanchard took a job at the Clarke,
where he has remained, recently taking Freund's position after his death.

Blanchard
is irreverent, cynical, and politically incorrect. During the opening
ceremony of the International Academy of Sex Research, during the eulogies
for members who died during the previous year, he regularly engages in
wickedly entertaining whispered commentary about the deceased, unsentimentally
recalled. (His eulogy for Freund, however, was serious and touching.)
He has little patience for arguments about whether research is good for
people (such as "Are homosexual people hurt or harmed by research
on the genetics of sexual orientation?"), preferring instead to dwell
on whether scientific findings are true. A transsexual colleague of Blanchard's
tells how she once sought his advice regarding a professional dilemma.
A member of a task force about transsexualism, she disliked the first
draft of their report, but was worried she would offend the other (nontranssexual)
members of the committee. Blanchard's characteristic advice: "What's
the point of being a sacred cow if you don't moo?"

Academics
remember each other by their "contributions," or ideas that
make a mark, ideas that get the attention of other academics, motivating
others to study the same thing. Blanchard has made two contributions so
far. His most recent work has shown convincingly that gay men tend to
have more older brothers compared with heterosexual men, and he is pursuing
an interesting biological theory to account for this. But I think his
more revolutionary contribution has been to the classification and explanation
of transsexualism. In a series of articles beginning in 1985 and continuing
for about a decade, Blanchard established that there are two very different
types of men who change into women, who have very different presentations,
motivations, and probably, causes. Blanchard's observations transformed
male-to-female transsexualism from a seemingly chaotic and bizarre collection
of phenomena into two straightforward and clinically comprehensible patterns.

*********

When
Ray Blanchard began studying and treating transsexuals during the early
1980s, the field was rife with different confusing diagnostic typologies,
including anywhere from one to four kinds of transsexuals. At a merely
descriptive level, most clinicians saw a similar array of gender patients.
First was the kind of transsexual that most of us think of when we hear
"transsexual," the classic, homosexual type, like Terese. From
soon after birth, these males behaved like, and desired to be, female.
No one who spent much time with them could be very surprised that eventually
they would choose sex reassignment surgery. Of all transsexual types,
this was the one that most seemed to consist of "women trapped in
men's bodies."

Another
type of transsexual that specialists recognized, but which is less familiar
and comprehensible to most people, was the heterosexual transsexual. These
males frequently came to treatment as married men who claimed to have
had hidden or suppressed longstanding wishes to be female that they could
no longer deny. The clinical picture of this type was much different than
the homosexual transsexual. Obviously, of course, one was attracted to
men and the other to women, but there was another striking difference.
Most heterosexual transsexuals, and virtually no homosexual transsexuals
reported a phase beginning during adolescence, in which they secretly
wore women's clothing such as lingerie, became sexually aroused, and masturbated.
Cher has a history that is characteristic of many heterosexual transsexuals.
However, she has had sexual fantasies about both men and women, and has
had sex with both. She is bisexual.

There
was at least one other type of transsexual that experts wrote about, one
that presented a much fuzzier picture. This was a transsexual type whose
sexuality was either unclear or absent. These transsexuals claimed to
be attracted to neither women nor men, and some of them claimed to have
no sexual feelings at all. Some called this type "asexual."

To
make matters more complicated, there were at least two other types of
man who cross-dressed, but who did not want sex changes. Drag queens were
gay men who cross-dressed in public, often for the purpose of entertainment
(especially lip synching and dancing to music). Transsexualism researchers
knew that drag queens existed, but did not know much about them, because
drag queens did not often seek treatment for their cross-dressing; it
caused them no problems. The other group of men who cross-dressed were
called transvestites. These were heterosexual men, typically married,
who dressed in women's clothing without any intention of getting a sex
change. Like heterosexual transsexuals, they frequently acknowledged an
erotic component to their cross-dressing, at least during adolescence.
The official psychiatric diagnostic manual of the time, The Diagnostic
and Statistical Manual of Mental Disorders(DSM III-R) called heterosexual
transvestism "transvestic fetishism," and put it in an entirely
different section of disorders from transsexualism. The diagnostic label
implied that transvestites are motivated by an erotic connection to women's
clothing. Heterosexual transvestites are an important part of this story,
and they are probably far more common than transsexuals (no one knows
for sure). So before proceeding, let's meet one.

*********

Stephanie
Braverman is, despite the name, a 50-ish married man who holds a high-level
position in a national bank, and whose wife is a well-known administrator
in a local university. When Stephanie is a man-which is most of the time-that
man is named "Don." I have never met Don. Stephanie always looks
the same, dressed in tastefully elegant style-wig, makeup, and all-as
a middle-aged matron. After reading about my interest in gender in a newspaper
article, Stephanie called me to "educate" me about heterosexual
cross-dressers. We have met several times, and I have learned much. Still,
we disagree fundamentally (if good-naturedly) about many things related
to cross-dressing. One thing we mostly agree on, however is her basic
story.

Stephanie
remembers Don having early (age six or so), vague wishes to be a girl,
but does not think that others found him remarkably feminine. In adolescence,
Don periodically wore his mother's lingerie, looked in a mirror, and masturbated.
He felt ashamed and guilty about cross-dressing, and tried to stop several
times, but each time was unable to refrain for long. In his early 20s,
he met the woman he would marry. Before proposing, he told her about his
cross-dressing and said that he intended to stop. His future wife, in
love with him by then, did not even pause to reconsider her commitment.
They have had, by most appearances, a successful marriage, with three
children. Several times, during the marriage, Don "purged,"
throwing away all his women's clothing and vowing to quit cross-dressing.
(Over all his purges, Don probably threw away several thousand dollars
worth of clothing.) Following each purge, he felt relieved and virtuous
for a time, but these feelings eventually transformed into irritability,
tension, and despair. Each time, Don gave in to his cross-dressing urges.
After his last (and final, Stephanie hopes) purge attempt failed, he sought
counseling, and his therapist helped him find the Chicago chapter of Society
for the Second Self (or Tri-Es), an organization for heterosexual cross-dressers.
Stephanie has become a leader in the chapter, and speaks frequently (and
always as Stephanie) to college students and other receptive audiences.
She wants ultimately to diminish the stigma felt by cross-dressers.

Stephanie
claims that the erotic component of cross-dressing was never Don's primary
motivation-which was the expression of an inner femininity-and that he
rarely feels aroused any more when cross-dressed. Once in a while, a glimpse
in the mirror of how good Don looks as Stephanie (especially his legs)
gives him an erection, but this is more annoying than satisfying. Stephanie
insists that the primary benefit of cross-dressing these days is relaxation.
When business and family duties prevent Don from cross-dressing for much
longer than two weeks, he feels tense and irritable. To me, it sounds
as if Don's cross-dressing was at one time primarily sexually motivated,
and indeed I suspect it still is to a large extent. This is our ongoing
argument, and I will return to it.

*********

Diagnosis
can advance by either splitting or lumping. Splitting occurs when someone
notices two or more superficially similar conditions that had previously
been called the same thing. The history of medical diagnosis has mostly
been a story about splitting. Some early classification systems, for example,
included the category "fever," which subsumed every problem
that caused a temperature. In contrast, modern diagnosis distinguishes
thousands of conditions that cause fever, from chicken pox to Ebola.

More
rarely, diagnosis progresses by lumping. Lumping occurs when two or more
apparently different conditions are found to be different forms of the
same, underlying pathology. In the early history of AIDS, doctors noticed
an increase in a variety of seemingly unrelated conditions, such as pneumocystitis
carinii pneumonia, Kaposi's sarcoma, and cytomegalovirus retinitis, among
gay men. Eventually, they hypothesized that these were all consequences
of the same infection, and when it was possible to test for HIV, its presence
was confirmed in virtually all cases.

Ray
Blanchard's contribution to transsexual science was of the lumping variety.
Distinguishing "homosexual," "heterosexual," "bisexual,"
and "asexual" transsexuals diagnostically makes sense only if
the different types have fundamentally different causes. Otherwise, why
not distinguish "tall," "medium-sized," and "short"
transsexuals, or "blonde" and "brunette" subtypes?
Blanchard noticed some similarities between some of the subtypes that
made him suspect that they were fundamentally similar. In particular,
the homosexual subtype seemed different from all the others, who seemed
similar in important respects. (In order to avoid wordiness, he called
the heterosexual, bisexual, and asexual transsexuals the "nonhomosexual"
transsexuals.)

For
one, the nonhomosexual types were older when they came to the Clarke Institute
for treatment. This was partly due to the fact that many of them had postponed
their gender concerns to raise families. But even the asexual subtype,
who was typically unmarried, came to treatment later than the homosexual
subtype. On average, the nonhomosexual types showed up at the Clarke eight
years later than the homosexual type. The nonhomosexual types also gave
somewhat different childhood histories than the homosexual type, who universally
acknowledged marked and noticeable femininity from early on. In contrast,
many of the nonhomosexual types said that they were unremarkably masculine
boys, though they typically reported early memories of secret longing
to be girls.

The
most noteworthy difference between the homosexual and nonhomosexual transsexuals
concerned cross-dressing. Homosexual transsexuals recalled that they cross-dressed
from early on, but few of them reported that cross-dressing provoked a
sexual response. Most nonhomosexual transsexuals admitted sexual arousal
to cross-dressing, at least in the past. Even the asexual subtype did
so.

Blanchard
made a good case that "heterosexual," "bisexual,"
and "asexual" transsexuals were more like each other than like
homosexual transsexuals, and he suspected that they were subtypes of a
more general condition. But what general condition? Then Blanchard saw
a patient named Philip, who proved to be the exception that revealed the
rule.

Philip
was a 38-year-old unmarried business executive who was referred to the
Clarke Institute of Psychiatry because of the persistent wish to be a
woman, accompanied by depression that he was not one. Philip was a happy,
masculine boy, who was popular and competent. Philip had cross-dressed
only once in his life, at age six. Although he lived alone and could cross-dress
easily, he simply had no desire to do so. Since puberty, he had masturbated
fantasizing that he was a nude woman, lying alone in his bed. He would
focus on the picture of having breasts, a vagina, and other female physical
characteristics. Although Philip had had sex with several women, there
were indications that this was not especially rewarding to him. In his
only long-term relationship, he stopped having sex with his girlfriend
after only a few months. In his last time with a woman, he had difficulty
getting an erection. He has never had sex with a man. However, he had
begun to fantasize about having intercourse with a man, as a woman. The
man in his fantasies was a faceless abstraction rather than a real person.
Philip never fantasized about having gay sex with a man, as a man.

Philip
was near the borderline of nonhomosexual transsexualism, but he lacked
a cardinal sign of that disorder, a history of erotic cross-dressing.
It dawned on Blanchard that what Philip had in common with most nonhomosexual
transsexuals, as well as cross-dressers for that matter, was sexual arousal
at the idea of himself as a woman. This strange sexual desire-for oneself
to be transformed into a woman-seemed to be the fundamental motivation
for nonhomosexual transsexualism. Blanchard called it "autogynephilia"
(pronounced Otto-guy-nuh-feel-ee-ya). "Gynephilia" means attraction
to women, and "auto" means self. Autogynephilia accounts for
a variety of phenomena that seem otherwise disconnected.

Take
cross-dressing. At the time that Blanchard came up with autogynephilia,
the prevailing explanation of erotic cross-dressing was that it was like
a fetish, a mere association of sexual arousal with inanimate objects.
But there were obvious problems with this conceptualization. Most men
find garter belts and bras to be sexy, probably because of their association
with scantily clad women, but most men do not put them on and look at
themselves in the mirror. Nor do cross-dressers merely wear women's clothing.
While cross-dressed, they typically pretend to be women: taking female
names, trying to walk and sometimes talk like women. According to Blanchard,
even cross-dressers who do not want to change their sex have autogynephilia,
which they share with nonhomosexual transsexuals. This is sensible because
during the teenage years, it is probably impossible to distinguish males
who will become nonhomosexual transsexuals from those who will remain
cross-dressers. They are all autogynephiles.

Autogynephilia
also accounts for the homosexual-like fantasies of some autogynephilic
(i.e., nonhomosexual) transsexuals. These fantasies are quite unlike the
homosexual fantasies of gay men and homosexual transsexuals. They do not
focus on characteristics of the male partner, but on the transsexual's
female self interacting with the male. Stephanie, the cross-dresser, once
told me a fantasy she had been having about me. In her fantasy, I would
treat her "like a lady,"-take her out to a nice restaurant and
then out dancing. She reassured me that she did not want to do anything
sexual with me (and I had never sensed that she was sexually attracted
to me). As she told me about the fantasy, however, it was clearly an erotic
one. But in contrast to gay men's fantasies about other men, I was merely
a prop in Stephanie's; I could have been any male. Even in more explicitly
sexual fantasies, the male usually has no face, just a penis and body,
which penetrates the imagined vagina. To many autogynephiles, the act
of being penetrated by a penis is the ultimate statement that one is a
woman, and this is perhaps why it is so arousing to some autogynephiles
(such as Cher).

Blanchard
noticed different forms of autogynephilia in the different patients he
saw. Some patients were sexually aroused by cross-dressing, others by
the fantasy that they were pregnant, others by the fantasy that they had
breasts, and others by the fantasy that they had vaginas. One patient
even masturbated while fantasizing about knitting in a circle of other
knitting women or being at the hairdressers with other women.

Blanchard
hypothesized that the type of autogynephilia that a man has should predict
whether the man would become transsexual. A cross-dresser with only transvestitic
or behavioral autogynephilia can probably satisfy his urges by periodically
cross-dressing in private or in the company of other transvestites. But
a man whose primary fantasy is having a vulva cannot enact his fantasy
so easily. (Not everyone is as creative as Cher, and eventually, wearing
fake vaginas did not work for her either.) Blanchard confirmed that, indeed,
it was men who fantasized about themselves as nude women, and who focused
on the image of having a vulva, who felt the strongest desire to change
their sex. He also found that patients who fantasized about themselves
as nude women were younger at their first appointment compared with those
patients who fantasized about themselves wearing women's clothing. This
suggests that autogynephilic transsexualism is not merely a progression
from cross-dressing. If it were, the patients who fantasized about cross-dressing
should have been younger, not older (because by the incorrect interpretation,
they would not have yet advanced to the "nude fantasizing" stage
of their condition).

Once
Blanchard asked a group of autogynephilic transsexuals: "Suppose
you had the following choice. You could get your sex reassignment surgery
but continue to live as a man forever or live as a woman but never obtain
sex reassignment surgery. Which would you do?" About half of the
group chose each alternative. Those whose autogynephilia focused on the
vagina chose the surgery, and those focused on the female role chose the
role change. Of course, most autogynephilic transsexuals want both.

*********

How
are we to think of autogynephilic men? Are they more like gay men, or
like heterosexual men? Do they really have a woman hidden inside them?
If so, why do they hide their inner femininity, when some gay men, drag
queens, and homosexual transsexuals are extremely and openly feminine
from an early age?

The
word "autogynephilia" is difficult, even jarring, and this is
appropriate-the concept it names is bizarre to most people. In order to
understand autogynephilia, it is important to recognize that it differs
so much from ordinary experience that it cannot be understood simply.
For example, even heterosexual people can understand homosexuality by
thinking, more or less accurately, "It's just as if I were attracted
to my own sex instead of the other sex." Autogynephiles are more
difficult to fathom.

Blanchard
believes that autogynephilia is best conceived as misdirected heterosexuality.
These men are heterosexual, but due to an error in the development of
normal heterosexual preference, the erotic target (a woman) gets located
on the inside (the self) rather than the outside. This is speculative,
and what causes the developmental error is anyone's guess.

Autogynephilia
is not primarily a disorder of gender identity, except in the obvious
sense that the goal of the transsexual is to become the other sex. At
the cross-dressers' meeting I attended, the wife of one of the men asked
me: "When they say they feel like women, how do they know what that
feels like?" This question, which reflected the woman's skepticism
about the men's account, is profound. How do we ever know that we are
like someone else? Unless you believe in extrasensory perception (and
I don't), the answer must be found in overt behavior, which somehow signals
fundamental similarity. Evidently, the woman did not get those signals
from the men. (If instead of being the wife of an autogynephile, she were
the sister of a homosexual transsexual, I doubt she would have asked an
analogous question.) The fact is that despite their obsession with becoming
women, autogynephilic transsexuals are not especially feminine. One told
me, for example:

I
had a fairly early onset (certainly before age six) of an intense desire
to be a girl (or "like a girl") physically; or to put it another
way, to be female--but not necessarily to take on the feminine gender
role. This took different forms as I grew older. To a six-year old, the
difference between boys and girls physically is not primarily genital:
girls wear long hair and dresses, and that's what I wanted. As I got older,
I grew to want other things: breasts, a vagina, menstruation, pregnancy.
In the early stages the dysphoria wasn't painful, like a wound; it was
more like a yearning for the unobtainable, like a thirst I couldn't quench.

However,
I didn't play with dolls, nor do many of the traditional feminine things
that the classic primaries often report. I didn't like to compete athletically,
and I was always afraid of getting hurt; but I liked model cars and airplanes,
and toy guns, too.

This
contrasts greatly with the childhood histories of homosexual transsexuals,
whose femininity was remarkable to anyone who observed them closely. Nor
are autogynephiles especially feminine adults. After all, most have been
married, and to most observers, appear to be conventional husbands. Autogynephiles
rarely have stereotypically female occupations. On the contrary, many
have served in the military. I even met one who was in the Green Berets.
Technological and scientific careers seem to me to be over-represented
among autogynephiles. (Ray Blanchard remarked to me that he saw a seemingly
close relation between autogynephilia and computer nerdiness.) Autogynephiles
have claimed that they chose stereotypically masculine occupations to
hide their feminine side, but I doubt this. It seems more consistent with
the overall picture to say that autogynephilia is not associated with
stereotypically feminine interests. Finally, autogynephiles do not typically
look or act very feminine, especially in comparison with homosexual transsexuals.
To the extent that autogynephiles achieve a feminine presentation, it
is with great effort. Cross-dressers attend workshops in talking, walking,
standing, and gesturing like women. The work usually pays off eventually
in a passable feminine presentation, but it is work.

Autogynephiles
are not "women trapped in men's bodies." (Anne Lawrence, a physician
and sex researcher who is herself a postoperative transsexual, has called
them "men trapped in men's bodies.") Homosexual transsexuals,
so naturally feminine from early on, can make this claim more accurately,
but as we shall see, it is not completely true even of them. Autogynephiles
are men who have created their image of attractive women in their own
bodies, an image that coexists with their original, male selves. The female
self is a man-made creation. They visit the female image when they want
to have sex, and some became so attached to the female image that they
want it to become their one, true self. This explains the name of the
transvestite organization "Society for the Second Self." It
also explains the maddening tendency of some autogynephilic research subjects
to put down two answers to every question-one by the female self, and
one by the male self. Homosexual transsexuals do not do this. They have
one self that is a mixture of masculine and feminine traits, and not alternating
selves. No, autogynephiles are not women trapped in men's bodies. They
are men who desperately want to become women.

*********

We
do not have even the beginnings of a respectable theory of the causes
of autogynephilia. This differs from sexual orientation, in which we have
a reasonably well articulated if unproven theory. Recall from Chapters
3 and 6 that femininity in boys and homosexuality in men is probably caused
by incomplete masculinization of the brain during sexual differentiation.

Autogynephilia
in the form of cross-dressing is still called "transvestic fetishism"
in the DSM IV-TR, and many people have suggested that fetishism arises
as a kind of conditioning experience. As the guy at the cross-dressers'
meeting put it, panties are sexy, so some men become aroused wearing them.
The problem with this account is that although it might explain a fetish
for panties, it does not explain why men should want to wear the panties.
Conditioning explanations of both sexual preferences and fears (the other
domain where they are common) have received little convincing support,
although many people believe them. Blanchard's conceptualization of cross-dressing,
as arousal to an image of oneself as a woman, is very different from the
idea of a fetish. Conceptualized Blanchard's way, it is difficult to see
how cross-dressing could arise through conditioning.

Some
autogynephiles claim that their first cross-dressing experience was in
the context of being punished (usually by some female friend or relative,
who forced them to cross-dress to humiliate them), and that this is how
they acquired their taste for cross-dressing. I find these reports dubious.
They sound more like fantasies or attempts to explain their behavior in
ways that sound plausible to others. In any case, the fact that most autogynephiles
do not claim these experiences suggests that they cannot be causally crucial.

Regarding
the fundamental question of whether autogynephiles are born or made, my
intuitions are with "born." Perhaps every day, in this country,
at least one adolescent boy by himself puts on his mother's or sister's
lingerie, becomes sexually aroused, and masturbates. As far as anyone
can tell, there is nothing unusual about the environments of these boys,
and certainly nothing in their environments obviously contributes to their
unusual preoccupation. This smells innate to me. (I do not claim to be
making a strong case here.)

Anecdotally,
I have heard several accounts of first-degree relatives (brothers, or
fathers and sons) who discovered that both were cross-dressers. The discovery
was invariably after both relatives had a great deal of cross-dressing
experience, which they had hidden from each other. This smells genetic
to me. Again, though, this is not meant to be a strong argument.

Autogynephilic
cross-dressing usually begins in late childhood or early adolescence,
but this does not mean that it is not biological. (Pubic hair also begins
at adolescence.) Some autogynephiles claim that they have early memories
of their condition, such as the desire to be female. I have tended to
be skeptical about these memories, but a recent case seen by psychologist
Ken Zucker at the Clarke Institute has made me more open-minded. This
was a three-year-old boy whose mother had brought him in to the clinic
because of his cross-dressing, which she first observed at around age
two. According to the mother, the boy wore her or his sisters' underwear,
lingerie, slips, and nighties. The mother also reported that (at age three!)
he got erections when looking at women's clothing in magazine advertisements,
and he would demand that she buy the items he was viewing. His cross-dressing
was sporadic, rather than continuous, and it did not appear to reflect
early femininity-he did not say he wanted to be a girl or have other feminine
interests, for example. The most fascinating development came when Zucker
interviewed the father, who admitted that he had cross-dressed erotically
since adolescence. There was no indication that the boy had ever seen
his father do this or had any opportunity to learn the behavior from him.
I predict (as does Zucker) that when he grows up, the boy is very likely
to have some variety of autogynephilia. His early onset also smells biological,
though as I stressed, early onset is not a necessary component of innate
behavior.

Highly
relevant to the nature-nurture question is whether autogynephilia has
occurred in most cultures and times. In fact, there is only very limited
evidence about its occurrence prior to Magnus Hirschfeld's classic work,
Die Transvestiten, published in 1910. There are a few more-or-less definitive
accounts, such as the AbbÈ de Choisy, who lived in France from
1644 until 1724. Although the historical record does not document Choisy's
masturbatory habits (he was, after all, a cleric), it is clear that he
was a heterosexual cross-dresser. He was romantically drawn to women,
whom he preferred dressed as men. In fact, he once arranged a marriage
ceremony in which he dressed as the bride, and the woman as the groom.
He clearly experienced cross-dressing, and particularly being admired
as a woman, as erotic. He had periods in which he felt guilty about his
unusual preoccupation and purged, just as contemporary cross-dressers
do.

The
cross-cultural occurrence of autogynephilia has not been well established
(in contrast to homosexual transsexualism, which has been). This is not
surprising. It is probably rare, secretive, and poorly understood. On
the other hand, I expect that it occurs everywhere. Blanchard has seen
autogynephilic transsexualism in immigrants from Europe and Asia.

In
order to progress scientifically toward the causes of autogynephilia,
it will be useful to keep in mind that autogynephilia seems to be a type
of paraphilia. Paraphilias comprise a set of unusual sexual preferences
that include autogynephilia, masochism, sadism, exhibitionism (i.e., exposing
one's genitals to strangers for sexual excitement), frotteurism (rubbing
oneself against strangers, such as in a crowded bus, for sexual excitement),
necrophilia, bestiality, and pedophilia. Because some of these preferences
(especially pedophilia) are harmful, I hesitated to link them to autogynephilia,
which is not harmful. But there are two reasons to think that these sexual
preferences have some causes in common. First, all paraphilias occur exclusively
(or nearly exclusively) in men. Second, paraphilias tend to go together.
If a man has one paraphilia, then his chances of having any other paraphilia
seem to be highly elevated. The best established link is between autogynephilia
and masochism. There is a dangerous masochistic practice called "autoerotic
asphyxia," in which a man strangles himself, usually by hanging,
for sexual reasons. Although autoerotic asphyxiasts arrange an escape
hatch-for example, a well placed stool they can stand on before it's too
late-sometimes things go wrong. Perhaps 100 American men every per year
die in this way. About one-fourth of the time, these men are found wearing
some article of women's clothing, such as panties. There is no obvious
reason why autoerotic asphyxia should require cross-dressing. Apparently,
these men are both masochistic and autogynephilic. Cross-dressing has
also been linked to sexual sadism-although most autogynephiles are not
sexual sadists, they are more likely to be sadists compared with men who
are not autogynephilic.

Paraphilias
tend to seem bizarre to typical gay and straight people, whose sexual
desires are primarily directed toward conventional sex acts with adults.
Social explanations of paraphilias tend to be strained and unconvincing.
What kind of experiences would make men risk their lives to become sexually
aroused from being strangled while wearing panties? I'm betting on biology.

My
gut feelings may say as much about my biases as they do about the evidence,
which is admittedly scanty. Other people might look at the same evidence
and reach the opposite conclusion. However, no one could honestly and
competently say that we are anywhere close to understanding the causes
of autogynephilia, or more generally, paraphilias.

*********

Suppose
a man-let's assume he is a famous entertainer, a singer perhaps-has undergone
a series of operations during his life to make himself look more feminine.
Suppose that he comes off as feminine in some other respects as well,
such as his speaking style. However, he denies being gay and, in fact,
has been married several times. What might explain this man's behavior?

There
are basically two possibilities. First, despite his protests to the contrary,
hemight actually be gay. Surprisingly, many people continue to believe
that being gay is still a liability in much of the entertainment industry,
although Elton John has pulled it off nicely. But if this man were the
member of a relatively anti-gay ethnic minority, say an African American,
it might be especially hard to come out. In this case, his marriages would
most likely be publicity stunts with cooperative women (as Doris Day was
with Rock Hudson).

If
this were the correct explanation, feminizing surgery would reflect homosexual
transsexualism. Remember, homosexual transsexuals want to become women
because they are innately feminine, but also because they want to become
beautiful sexy women to attract men. They employ feminizing surgery across
their entire bodies-hips, breasts, and if necessary, face-in very sexy,
flattering ways. If surgery did not lead to a flattering appearance, and
if it were restricted, say, to the face, this would not be the typical
picture of a homosexual transsexual.

A
homosexual transsexual would almost certainly have a series of sexual
relationships with masculine straight men. These could be difficult to
hide, depending on the tabloids' interest level.

The
second likely possibility is that the singer is autogynephilic. Autogynephiles
also are motivated by the desire to become more feminine. In contrast
to homosexual transsexuals, however, they are not trying to become generally
beautiful and sexy women in order to attract men. They create certain
feminine traits in themselves to fulfill their own sexual desires. Although
some autogynephiles want everything, others are content with very limited
feminizing steps. Autogynephiles frequently have very specific desires-to
have breasts, for example, or to have a vagina, or to have a feminine
face, or to wear a garter belt. This would never be true of a homosexual
transsexual. If the entertainer were autogynephilic, his marriages might
well have been real sexual relationships, although autogynephilia might
tend eventually to strain them.

Information
that could help decide what was motivating our entertainer would include
stories from childhood and adolescence. If the entertainer is a homosexual
transsexual, then he was almost certainly a markedly feminine boy. Anyone
who knew him well during childhood would know that he enjoyed playing
with dolls, for example, or dressing up like a girl. If he were an autogynephile,
his childhood would not have been remarkable in this way. His adolescence
probably would have been unusual. If the entertainer is an autogynephile,
then most likely as a teenage boy, he cross-dressed fetishistically-put
on women's lingerie in private and masturbated while looking at himself
in the mirror. Although many autogynephiles have traumatic stories of
being discovered while cross-dressing, many successfully hid their secret.
So even if the singer is autogynephilic, relevant information on adolescence
might never surface.

Other
relevant information would include knowledge about his other sexual proclivities.
For example, if the singer liked to cross-dress during sex with his wife,
that would be a sure sign of autogynephilia. Also, remember that autogynephilia
is a paraphilia, and paraphilias often run together. If we knew that the
singer had another paraphilia, this would increase our confidence in a
paraphilic interpretation of his behavior. This would be particularly
true if he was a masochist, for example, because the link between autogynephilia
and masochism has been clearly drawn in research studies. But I think
that even if he had a paraphilia that no one has yet linked to autogynephilia-pedophilia
for example-we should still move toward autogynephilia. No multimillionaire
homosexual transsexual would waste his time and money and risk everything
to have sex with a prepubertal or pubescent child, even a boy. Like other
males, homosexual transsexuals favor youthful sex partners, but their
prototypal Adonis is a 20-year-old man. Knowing that our singer had sexual
interest in children would certainly sway me in favor of autogynephilia.
(I note here that Anne Lawrence disagrees with me. And even if I am correct,
the vast majority of autogynephiles have no sexual interest in children.)

Privacy
might prevent us from ever knowing the truth, but these are the kinds
of things we would want to know.

*********

"Most
gender patients lie," says Maxine Petersen, the ace gender clinician
at the Clarke. One common lie among autogynephiles, according to Petersen,
is that they are homosexual rather than heterosexual. The motivation for
that lie is probably the fear that a gender clinic will deny them a sex
change if they are determined to be heterosexual. And indeed, some psychiatrists
have taken the position that nonhomosexual transsexuals are uniquely inappropriate
for sex reassignment because they are not "true" transsexuals.
(The Clarke Institute does not discriminate against autogynephiles and
indeed, Blanchard wrote an uncharacteristically impassioned passage in
one article urging readers not to use his findings to justify such discrimination.
However, as recently as 1989, Blanchard and his colleagues from the Clarke
opined that "heterosexual applicants for sex reassignment should
be evaluated with particular caution" because of an increased likelihood
of postoperative regret.) Autogynephiles who claimed to be homosexual
transsexuals could account for the apparent cases of homosexual transsexuals
who practiced erotic cross-dressing. Other common lies, according to Petersen
and others, include an exaggeration of early femininity. This might in
some cases have the same motivation.

The
most common way that autogynephiles mislead others is by denying the erotic
component of their gender bending. For example, when Stephanie Braverman
lectures to my human sexuality class, she does not even mention her history
of masturbating while cross-dressed. When I spoke at a meeting of Chicago
cross-dressers, the men became clearly uncomfortable when I brought up
the erotic component of their activity, preferring instead to attribute
it to their inner femininity. When I pointed this out, one cross-dresser
said "I wear feminine clothing because I feel feminine, and I can't
help getting aroused because the clothes are sexy. Any man would."
I don't think so. But you can judge. Here is one of the passages that
aroused the cross-dressers in Blanchard's study. See if you think it is
sexy.

"You
have plenty of time to dress this evening. You slip your panties over
your ankles and pull them up too your waist. Sitting on the edge of your
bed, you put on a pair of sheer nylon stockings. You fasten the stockings
with the snaps of your lacy garter belt. You slip your arms through the
straps of your brassiere and reach behind you to fasten it. You put on
your eye shadow, mascara, and lipstick. Lying on your bed, you look up
at your reflection in the large mirror on the ceiling."

Why
do some autogynephiles deny the sexual component of their condition? One
reason, again, is the real or imagined treatment implications. Some psychiatrists
refuse to recommend for sex reassignment any man who has had even one
incident of erotic cross-dressing. But this fear surely cannot explain
the resistance of Stephanie Braverman and the cross-dressers at the meeting-they
are not trying to become women.

Perhaps
the major reason is shame and assumed social reaction. The physician Harry
Benjamin, who popularized the word "transsexual," noticed early
on that cross-dressers, and especially cross-dressers in organizations
trying to influence the public, tend to de-emphasize the erotic element.
He suggested that they do this in order to be more accepted by others.
Today, public statements by those who call themselves "transgendered"
(who are almost all autogynephiles rather than homosexual transsexuals)
rarely acknowledge any erotic component of "transgenderism."

There
is also a more personal motivation to deny the erotic component of autogynephilia.
Anne Lawrence put it this way:

I
imagine most men would be humiliated to admit that dressing in women's
clothing is a sexual kick, and even more humiliated to admit that doing
so, or fantasizing doing so, is obligatory for climax some or all of the
time. Just dressing in women's clothing is shameful enough; but having
one's sexual potency contingent upon such an unmanly, "ridiculous"
crutch would be almost impossible to admit. Moreover, for anyone who thinks
about it, the whole experience of reliance on paraphilic behavior or fantasy
for arousal is rather tragic and lonely: it cuts one off from intimate
contact during partnered sex, because one is (at least mentally) often
making love to oneself rather than to one's partner. Better not to admit
this to anyone--especially to one's wife. I think that if the wives of
heterosexual cross-dressers knew what their husbands were really thinking
about at the moment of climax, they would be appalled. (Of course, this
might apply to the wives of other straight men as well; but it's one thing
to learn he's fantasizing about making love to Claudia Schiffer, and another
to learn he's fantasizing about being forced to wear a French maid's outfit.)
On the other hand, to attribute one's cross-dressing to a desire to express
one's "feminine side" is much more acceptable. Though the behavior
may still appear ridiculous, the putative rationale allows the cross-dresser
to portray himself as multi-faceted, courageous, and even empathic with
his spouse. That's a far easier script for most men to follow.

In
my experience, most lay people are happy to accept the "I'm a woman
in a man's body" narrative, and don't really want to know about autogynephilia-even
though the preferred narrative is misleading and it is impossible to understand
nonhomosexual transsexualism without autogynephilia. When I have tried
to educate journalists who have called me as an expert on transsexualism,
they have reacted uncomfortably. One said: "We just can't put that
into a family newspaper." Perhaps not, but then, they can't print
the truth.

There
is one more reason why many autogynephiles provide misleading information
about themselves that is different than outright lying. It has to do with
obsession. Something about autogynephilia creates a need not only to enact
a feminine self, but also to actually believe in her. It seems important
to them to emphasize the permanence of the feminine self as well as her
primacy: "I was always feminine, I just managed to hide it. I became
a Green Beret as a defensive response to my femininity." In such
accounts, the feminine self is the real self; the masculine self is the
creation. (I have been arguing that the opposite is closer to the truth.)
Intersexuality refers to congenital conditions in which biological sex
is ambiguous, usually due to hormonal or genetic problems. Cheryl Chase,
the intersex activist, told me that transsexuals frequently join intersex
groups because they are convinced that they are also intersexual. In most
cases, they are not. I assume that these are autogynephilic transsexuals
who want to believe that there is a real biological woman inside them
as well as a real psychological woman.

The
self-presentational deceptiveness of some autogynephiles is a main reason
why autogynephilia was not understood until recently. Many clinicians-even
some who write books-have taken the information that transsexuals tell
them at face value. I recently attended a talk by a well-known psychologist
at an academic sex conference in which she presented a case that was clearly
autogynephilic (he'd been married and was in his late 40s, among other
signs). However, she spoke not one word about her patient's sexual fantasies,
dwelling instead on the usual "woman trapped in man's body"
story. Blanchard's ideas have not yet received the widespread attention
they deserve, in large part because sex researchers are not as scholarly
as they should be and so don't know read the current scientific journals.

And
although Blanchard's ideas are fundamental to an understanding of transsexualism,
they might not matter that much for helping transsexuals, which most clinicians
have as their first priority. With luck, the next revision of the DSM
will distinguish "homosexual" from "autogynephilic"
transsexualism. But will popular features on "the transgendered"
begin to mention the teenage masturbatory cross-dressing? Will "The
Cher Mondavi Story" become a made-for-television movie co-starring
"Robot Man?" Probably not, and it is a pity. True acceptance
of the transgendered requires that we truly understand who they are.